Medicare Advantage

Forms & Information

Summary of Benefits

The Summary of Benefits describes some features of our plans, including premiums and cost-sharing. It doesn't list every service that we cover, or every limitation or exclusion.

2016 Summary of Benefits (pdf)


Evidence of Coverage

The Evidence of Coverage or "EOC" gives you complete details about your New West Medicare plan benefits, premiums, and cost-sharing amounts.

2016 Evidence of Coverage - Basic Plan (pdf)
2016 Evidence of Coverage - Value Plan (pdf)


Prior Authorization

2016 Prior Authorization Requirements

2016 Medical Drugs Requiring Prior Authorization (pdf)

How to request a retroactive authorization of medical services (pdf)
You, your doctor, or your representative can request a decision about Medicare care or services, called a “coverage determination” or “organization determination”, by calling, writing, or faxing us at:

Call
1-800-290-3657, TTY 711, choose Option 2
Hours are 8:00 am to 8:00pm daily.
Fax
1-406-457-2298
Write
New West Health Services
Attn: Medical Services
130 Neill Avenue
Helena MT 59601

Please also refer to your Evidence of Coverage, Chapter 9 for more information.

Appeal rights & instructions for filing: Part C (Medical) Appeals (pdf) or Part D (Prescription Drug) Appeals (pdf)


Other resources and forms

Learn about the Silver & Fit exercise and healthy aging program

Medicare Appointment of Representative Form (pdf)

HIPAA authorized representative form (pdf)
You have the right to elect someone to help you with your claims and discuss your coverage. If you need this assistance, this form tells you how to make that arrangement.

New West Notice of Privacy Practices (pdf)

Multi-language Interpreter Services (pdf)
Non Plan Provider Waiver and Appeal Form (pdf)